Every finding on record at Focused Care at Odessa

Based on observation, interview, and record review, the facility failed to maintain all mechanical, electrical and patient care equipment in safe operating condition for 1 of 1 laundry room reviewed for physical environment. The facility failed to maintain the clothes washers in working condition. This failure placed residents who relied on the facility for laundry services improperly cleaned clothes and diminished quality of life. Findings included:Review of Resident #1's admission Record, dated 5/21/26 revealed she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included End Stage Renal Disease (kidney no longer works the way it needs to). Resident #1 was on dialysis. Review of Resident #1's Quarterly MDS Assessment, dated 5/20/26 revealed:She had a BIMS score of 15 of 15 (indicating her cognition was intact) and showed no signs of delirium.She needed supervision or cueing for most ADLs. In an observation and interview on 5/21/26 at 9:20 a.m. the Laundry Supervisor stated the facility did have problems with the industrial washer breaking down; the hot water was not getting hot. The Laundry Supervisor stated the facility had to use special soap for resident clothing and she did not get the order in on time. The Laundry Supervisor stated it would delivered on 6/1/26. The Laundry Supervisor stated the soap used on the bed linens and towels would eat the resident's clothing. The Laundry Supervisor said she did not get the credit card from the Housekeeping Supervisor to get regular soap for resident's clothing out of petty cash or ask a sister facility for the right soap. The Laundry Supervisor said she did not know she did not ask to trade with a near by facility under the same corporation umbrella. The Laundry Supervisor stated sometimes the aides would not clean the bowel movement off the sheets or wrap the linens around a soiled brief. The Laundry Supervisor said the Laundry Department did not have a hopper (specialized sink for washing off BM from linens) equipped in the room. The Laundry Supervisor said the third washer may or may not work on getting the resident's clothes clean and the laundry staff were doing half loads in the washer. Observation at that time of the smallest washer (consumer sized) showed the washer was over filled with sheets - there were too many sheets for the agitator to move the sheets. The Laundry Supervisor stated the industrial washer was essential equipment for the facility to have linens. In an interview on 5/21/26 at 9:47 a.m., the Housekeeping Supervisor said there were three different laundry detergents she could order off the computer and the other laundry soap was for the small washer. The Housekeeping supervisor said she did not know to order the soap from the chemical company. In an interview on 5/21/26 at 12:07 p.m., Resident #1 stated the facility had two washers and the clothes came back stinking. Resident #1 said she talked to the head of laundry about it and was told the facility did not want to pay for a new washer. Resident #1 said the facility washed the poop linens in the same washer as the resident's clothes and that was why they stunk. In an interview on 5/22/26 at 1:13 p.m., CNA B stated she was not aware of any laundry complaints. She stated the laundry was able to keep up with the demand for linens. CNA B said the washing machine broke the week of 5/11/26 thru 5/15/26 but the facility got it fixed. CNA B stated the facility had enough back up linens to get through. In an interview on 5/22/26 at 1:34 p.m., CNA C stated showers were given the best CNAs could. CNA C said there were sometimes issues with getting enough linens, and sometimes the residents went without showers. CNA C said the last time the facility was short on linens was the week before when the washer broke again. CNA C stated the linens did not smell but she did not know if they were clean because she did not smell bleach on the towels. Review of washing machine repair receipts dated 2/27/26, 3/11/26, 3/23/26 revealed the facility had routine maintenance completed on the washing machine Interview on 5/21/26 at 10:50 a.m. the Administrator said there was no policy for essential equipment.

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services including procedures that assured the accurate acquiring and administering of all medications to meet the needs of 1 of 5 (Resident #1) residents reviewed for pharmacy services in that: MA A failed to ensure Resident #1 took her medications at the time of administration and left them on the bed side table. This failure could place residents at risk for medication overdose, medication under-dose, drug diversion, and not receiving therapeutic doses of prescribed medications. The findings included:Review of Resident #1's admission Record, dated 5/21/26 revealed she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included End Stage Renal Disease (kidney no longer works the way it needs to). Resident #1 was on dialysis. Review of Resident #1's Quarterly MDS Assessment, dated 5/20/26 revealed:She had a BIMS score of 15 of 15 (indicating her cognition was intact) and showed no signs of delirium.She needed supervision or cueing for most ADLs. Review of Resident #1's Care Plan, initiated 8/6/24, revealed:Focus: History of End Stage Renal Disease.Goal: Resident will have no signs or symptoms of kidney failure throughout the review date.Interventions: Administer medications as ordered. Review of Resident #1's Order Summary, dated 5/21/26 revealed:No orders for self-medicationShe received dialysis services.She received Sevelamer Carbonate tablets 800 mg by mouth (a phosphate binder used to control high levels of phosphate levels for people on dialysis) at meal times for End Stage Renal Disease. An observation and interview with Resident #1 on 5/26/26 at 3:34 revealed two large pills in a medication cup on Resident #1's bedside table. There were no staff present. Resident #1 stated she was asleep when medication was delivered, but it was just the phosphate binders. The DON was brought to Resident #1's room and shown the pills. The DON stated the medications needed to given with staff supervision and given with meals. In an interview on 5/27/26 at 10:08 a.m. with the ADON and DON, the ADON stated she just in-serviced staff about not leaving medication unattended on 4/15/26. The ADON stated it was just a routine in-service and not one initiated because of an issue. The DON, who was present, stated she talked to the MA who said Resident #1 did not want to take the medication at the time of medication pass. The DON said the MA should have brought the medication to the cart. The DON said she did not know why the medications were left at bedside. The DON said the risk to the resident was the resident could take the medication at the wrong time, or take a double dose of the medication, if the resident even took the medication at all. The DON stated other residents could take the medication when Resident #1 left her room for smoke breaks which could cause choking or adverse reactions. The DON stated MA A had been a CNA for a long time, but had only been a MA for a few months. The DON stated MA A was not a MA the last time she did MA competency checks. In an interview on 5/27/26 at 10:41 a.m., MA A stated she had been a MA for 2 - 3 months. MA A said Resident #1 told her (MA A) that she (Resident #1) was eating. MA A said Resident #1 usually took her pills while eating and said Resident #1 told MA A she would take them but did not. MA A stated she told Resident #1 to take the pills, but Resident #1 was a her way or no way resident. MA A stated the risk to the residents was someone could go into the room and take them and the other resident could get sick from taking the wrong medication. MA A stated this was the first time Resident #1 did not take her medications to MA A's knowledge. MA A said Resident #1 usually took her medications while MA A gave the roommate her medications. MA A said not leaving the medications unattended was covered in her class and she should've known better. Review of the facility's MA Competency checklist, undated, revealed one of the items on the checklist was: Remain with the resident until all medications have been taken. Review of the facility's in-service dated 4/15/26, by the DON revealed the subject of the training was, Please ensure residents take all medications in the cup. Do not leave medications at bedside. MA A did not participate in the in-service

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food for 1 of 1 kitchen in accordance with professional standards for food service safety.1. The facility failed to discard cabbage in a box dated 12/8/2025, containing brown and rotted leaves, in the reach-in cooler.2. The facility failed to ensure an opened bag of grits in the dry storage room was properly sealed and dated.These failures could place residents at risk for food borne illness.The findings included:1. Observation on 1/6/2026 at 9:00 AM in the reach-in cooler revealed 2 boxes of raw cabbage with a label indicating it was received on 12/8/2025. The box was opened, and cabbage was visible; approximately 25% of the cabbage leaves had turned black or were rotten.2. Observation on 01/6/2026 at 9:15 AM in the dry storage room revealed a bag of grits on a rack. The bag had been opened and was rolled over. The bag was not sealed or placed in a sealed bag or container. There was also no open date on the grits.During an interview on 01/6/2026 at 9:10 AM, the Food Service Supervisor stated the truck had just come in and they didn't have time to clean the refrigerator yet. All dietary staff were responsible for properly labeling and dating food items stored in the cooler and discarding items past their use-by dates or if it was of poor quality.During an interview 01/6/2026 at 9:20 AM the Food Service Supervisor stated the bag of grits should have been placed in a sealed bag, and failing to ensure food was properly sealed could result in deterioration in food quality and potential contamination from pests.During an interview 1/6/2026 at 2:00PM the Administrator stated the bad cabbage should have been removed and the grits properly stored. The Administrator stated failing to do so could result in deterioration in food quality, food borne illnesses, and contamination from pests. Record review of facilities policy titled Food Storage dated 4/1/2022 revealed:Food is delivered at the appropriate temperature and inspected prior to storage for signs of contamination.b. Packages remained properly sealede. Food product in good quality 6. Food removed from its original packaging will be labeled with the following a. Received date b. Open date c. Contents in the Package 9. Opened package or leftover food is to be tightly wrapped or covered in airtight, clean containers. It should be labeled, dated with opened or use by date. Do not keep leftovers in the refrigerator for more than 7 days.Record review of FDA Food Code 2022 in part revealed:3-302 Preventing Food and Ingredient Contamination3-302.11 Packaged and Unpackaged Food - Separation, Packaging, and Segregation.(A) FOOD shall be protected from cross contamination by:(4) Except as specified under Subparagraph 3-501.15(B)(2) and in (B) of this section, storing the FOOD in PACKAGES, covered containers, or wrappings(7) Storing damaged, spoiled, or recalled FOOD being held in the FOOD ESTABLISHMENT as specified under S 6-404.11

Based on observation, interview and record review the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public for 1 of 1 set of window blinds in room [ROOM NUMBER] and 1 of 1 resident smoking areas. 1. The facility failed to ensure the blinds were not broken.2. The facility failed to ensure adequate cleaning in the designated smoking area. These failures placed the staff, residents, and visitors at risk of living, working and visiting in an unsafe, unsanitary, and uncomfortable environment. Findings include: Observation on 01/06/2026 at 10:04 AM revealed the blinds were broken in room [ROOM NUMBER]. Both Bed A and Bed B were occupied and not interviewable. Observation on 01/07/2026 at 10:05 AM revealed the ground around the outside patio and the ground of the smoking area was littered with smoked cigarette butts. During an interview on 01/08/2026 at 11:05 AM with the Administrator, she stated there was not a policy for cleaning the smoking area. She said her expectation was for maintenance staff to clean all grounds daily, including the smoking area. During an interview on 01/08/2026 at 11:20 AM with the Regional Maintenance Supervisor, he said the staff utilized a chart for documenting when the smoking area was cleaned. He said the requirement was three times per week. He said that his expectation was for the smoking area to be free of litter and cigarette butts to prevent fire hazards. He said an ashtray and metal bucket were provided for cigarette butts. During an interview on 01/08/2026 at 3:23 PM with the DON, she said she was aware of the broken blinds in room [ROOM NUMBER]. The DON said the resident did it and the blinds had been replaced once already. She said they could be a safety issues and a privacy issue. During an interview on 01/08/2026 at 3:50 PM with the Administrator, she said the cigarette butts littering the ground were an issue of cleanliness and a safety hazard. She said maintenance staff was responsible for keeping the smoking area clean and free from litter, including cigarette butts. Record review of the facility's Smoking Policy, dated 10/12/2022, revealed It is the policy of this community to accommodate residents who desire to smoke, including electronic cigarettes by taking reasonable precautions, providing a safe environment for them, and protecting the non-smoking residents. Record Review of the facility's Smoking Area Weekly Cleaning Log for December, 2025 and January, 2026, revealed Smoking Area will be cleaned 3 times a week. Each Monday, Wednesday and Friday in December was marked as complete with a staff member's initials. Monday, January 5th and Wednesday, January 7th was marked as complete.

Based on record review and interviews, the facility failed to ensure residents were informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment for 1 resident (Resident #2) of 3 residents reviewed for informed consents.The facility failed to obtain a signed informed consent based on information of the benefits, risks, and options available for Resident #2 prior to administering an increased dose of Seroquel, a psychotropic medication (a psychoactive drug taken to exert an effect on the chemical make-up of the brain and nervous system).This failure could place residents at risk of receiving medications without their prior knowledge or consent, or that of their responsible party or being aware of the benefits and risks of the medications prescribed.Findings Included:Record review of Resident #2's admission Record, dated 01/08/2026, revealed he was a [AGE] year-old male originally admitted to the facility on [DATE] with diagnoses which included metabolic encephalopathy (a problem in the brain caused by a chemical imbalance in the blood), diabetes mellitus (a group of diseases that affect how the body uses blood sugar), and Alzheimer's (the most common form of dementia).Record review of Resident #2's Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score was not available due to the resident not being able to complete the interview. Record review of Resident's #2's Care Plan, dated 10/22/2025, revealed: Focus - The resident is on antipsychotic medication Seroquel r/t: behavior disturbance. Goal - Resident will show decreased number of episodes of hallucinations throughout the next review date. Interventions - Administer medications as ordered. Monitor/document for side effects and effectiveness. Educate resident/family regarding medication risks and benefits. Monitor/record occurrence of targeted behavior and document per protocol. Obtain consent from resident or RP prior to medication use. Pharmacy and physician to review resident's medication profile for continuing usage monthly.Record review of Resident #2's physician orders for Seroquel, printed 01/08/2026, revealed Seroquel Oral Tablet 25mg (Quetiapine Fumarate), give 1 tablet by mouth two times a day for behaviors, was ordered 09/15/2023. The physician orders revealed the dose was changed on 04/19/2024 to Seroquel Oral Tablet 50mg (Quetiapine Fumarate), give 1 tablet by mouth two times a day for behaviors.Record review on Resident #2's consents reflected a consent for Seroquel Oral Tablet 25 MG twice daily for behaviors was signed by his responsible party on 09/18/2023. There was not a consent for the increased dosage.In an interview on 01/08/2026 at 11:00 AM the DON said she would look for an updated consent. The DON said she was not aware of the necessity for a new consent when doses were increased. In an interview on 01/08/2026 at 1:05 PM the DON said she did not have an updated consent for the increased Seroquel dosage for Resident #2. She said the DON and the ADON were responsible for medication consents. The DON said the consequence of not having a new consent signed by the resident's responsible party could cause the responsible party to not be aware of the risks and side effects of an increased dose. On 01/08/2026 at 6:30 PM the DON was unable to supply a policy on consents prior to exit. She stated she did not think there was a policy addressing consents for psychotropic medications specifically.

Based on observation, interview, and record review, the facility failed to ensure residents have a right to personal privacy for 1 of 4 resident (Resident #13) reviewed for privacy, in that: CNA A and CNA B did not completely close Resident #13's window blinds while providing incontinent care and a change of clothes for the resident. This deficient practice could place residents at-risk of loss of dignity due to lack of privacy.The findings include: Record review of Resident #13's admission record dated 01/08/2026 revealed she was admitted to the facility on [DATE] with diagnosis of dementia, muscle wasting and atrophy. She was [AGE] years of age. Record review of Resident #13's MDS assessment dated [DATE] revealed: Cognitive Skills for Daily Decision Making = Severely impaired - never/rarely made decisions. Bladder and bowel = Urinary Continence - Frequently incontinent. Bowel continence = Always incontinent. Record review of the current care plan for Resident #13, last reviewed/revised: 01/07/2026, revealed in part: Resident is incontinent at times of: Bowel and bladder. Resident will remain clean, dry, and odor free with no occurrence of skin breakdown throughout the review date. Monitor for incontinence Q2H/PRN, change promptly and apply protective skinbarrier. During an observation on 01/06/2026 at 9:36 AM revealed CNA A and CNA B performed incontinent care and changed Resident #13's clothing. Both CNAs put some gloves on and proceeded to perform the resident care. CNA A then proceeded to undo Resident #13's brief and took some wet wipes to wipe the resident's vaginal area and rectal area. Resident #13's private areas were exposed during the care. CNA A and CNA B then put some pants on Resident #13. CNA A then transferred the resident to her wheelchair, removed her shirt which exposed her breasts and helped the resident put another shirt on. During the resident care the window mini blinds was noted to be open and faced the parking lot area where people would pass by. During an interview on 01/07/2026 at 11:30 AM CNA A and CNA B said they should have closed the window blinds before they performed the personal care for Resident #13. The CNAs said by not closing the blinds the resident could be exposed to the outside while she was nude during the personal care. The CNAs said they had not noticed the blinds were not fully closed. During an interview on 01/08/2026 at 3:30 PM the DON said her expectations was for staff to knock on the door, close the door, pull the privacy curtain, and close the blinds during personal care to provide privacy for the resident. The DON said the failure probably occurred due to staff getting nervous. The DON said the ADON would perform proficiency checks upon hire and yearly or more frequent if needed. During an interview on 01/08/2026 at 4:24 PM the Administrator said the expectation was for the staff to close the door, pull privacy curtain, and close the window blinds during personal care. The Administrator said they should have closed them to provide privacy for Resident #13. The Administrator said the CNAs failed to close the blinds probably because they were nervous. Review of the facility's policy titled Quality of life - Dignity dated August 2001 revealed in part: Each resident shall be cared for in a manner that promote and enhances quality of life, dignity, respect and individuality. Residents will be treated with dignity and respect at all times. Staff shall promote, maintain and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures.

Based on interview and record review, the facility failed to ensure allegations of abuse were reported immediately, but not later than 2 hours after the allegation was made to the State Agency for 1 of 4 residents (Resident #20) reviewed for abuse in that: The facility did not report to the State Survey Agency that Resident #20 reported an allegation of abuse to the administration within 2 hours of the incident. This deficient practice could place residents at risk for not having all allegations of abuse and neglect reported to the State Survey Agency in a timely manner.Findings Include: Record review of Resident #20's admission record dated 01/07/2026 revealed he was admitted to the facility on [DATE] with diagnosis of Parkinson's disease, schizophrenia, muscle wasting and atrophy. He was [AGE] years of age. Record review of Resident #20's MDS assessment dated [DATE] revealed in part: BIMS = 5 indicating severe impairment. Mobility devices wheelchair. Functional abilities - Chair/bed-to-chair transfer: The ability to transfer to and from a bed to a chair (or wheelchair) = Dependent - Helper does all of the effort. Resident does none of the effort to complete the activity Or, the assistance of 2 or more helpers is required for the resident to complete the activity. Record review of the current care plan for Resident #20, last reviewed/revised: 11/05/2025, revealed in part: The resident has limited physical mobility related to weakness. The resident will maintain current level of mobility through review date. The resident uses wheelchair for locomotion on and off unit, requires limited to extensive staff assistance to propel. The resident is dependent on staff for assistance with transferring X 2 person assist using Hoyer lift. The resident requires extensive staff assistance with bed mobility. Record review of an undated note written by CNA F indicated in part [CNA F] saw [LVN C] grab Resident #20 and pulled him by his shirt and pulled him up in an abusive manner I was walk to lay him down and I asked him for help and that when pulled him in abuse manner I look at [Resident #20] and he stated I think he broke my leg all I could do was say I'm sorry and I cried because I thought it was very wrong signed [CNA F]. Record review of LVN C's facility's Disciplinary Action Record dated 01/02/2026 revealed in part: Recommended action - suspend. Facts regarding incident: Violation of policy - Resident [#20] states pulled him up with shirt. Corrective action to be taken suspension for 3 day. Team member signature and date = done over phone. Record review of LVN C's facility's employee termination form dated 01/06/2026 revealed in part: Reason for separation failure to adhere to company policies. Description of incident: Resident [#20} states employee [LVN C] pulled him up by his shirt. During an interview and observation on 01/07/2026 at 3:40 PM revealed Resident #20 was in his bed awake and alert. Resident #20 said that LVN C had been rude to him. The resident said he felt intimidated by him just by the way the LVN looked at him. Resident #20 said whenever LVN C was working at the facility and was his nurse, he felt scared and threatened by the LVN. Resident #20 said he did not recall if he had reported LVN C to someone. Resident #20 said he did not recall being physically mistreated by LVN C just that he felt the LVN did not like him. During a telephone interview on 01/08/2026 at 3:04 PM the state surveyor called LVN C and a message was left to call back but the LVN never returned the calls. During an interview on 01/08/2026 at 3:42 PM the DON said regarding Resident #20 that there was a note found under the SW's door that indicated that LVN C had aggressively pulled the resident up on his Broda-chair (a type of reclined wheelchair). The DON said that occurred on or about 12/30/2025 and LVN C was suspended via phone call as LVN C was off from work when the allegation occurred. The DON said after the suspension LVN C was terminated due to the incident with Resident #20. The DON said that the Administrator had called LVN C on 01/07/2026 to terminate him over the phone. The DON said she was not sure if the Administrator had reported the allegation to the state. During an interview on 01/08/2026 at 4:45 PM the Administrator said LVN C had been suspended due to the allegation made by CNA F and the allegations of LVN C being inappropriate. The Administrator said she had done a safe survey to investigate the allegation brought against LVN C. The Administrator said CNA F had no phone to be reached at and the CNA had not returned to work after the note was left in the SW designee's office on 01/02/2026. The Administrator said she and the SW designee had interviewed Resident #20 on 01/02/2026. The Administrator said she had interviewed Resident #20 with the SW designee present and the resident had said he was sliding down his chair and that LVN C had pulled him up by his shirt. The Administrator said they did safe surveys and some of the residents did say they were scared of LVN C as he was intimidating. The Administrator said she had not reported the allegation to the state because the resident said LVN C had only pulled him up by his shirt. The Administrator said the letter was found under the SW designee's door on Friday 01/02/2026. During an interview on 01/08/2026 at 5:05 PM the SW designee said she remembered finding the note on the floor when she entered her office on Friday morning 01/02/2026 and that she had handed it to the Administrator. She said she did not know why CNA F had placed the note under her door instead of the Administrator's office. Record review of the facility's Abuse policy dated 02/01/2017 revealed in part: The purpose of this policy is to ensure that each resident has the right to be free from any type of abuse, neglect, intimidation, involuntary seclusion/confinement and or misappropriation of property. All events that involve an allegation of abuse or involve a suspicious serious bodily injury of unknown origin must be reported immediately or not later than 2 hours of alleged violation.

Based on interview and record review, the facility failed to have nursing staff with appropriate competencies to provide nursing and related services to assure resident safety and attain/maintain the highest practicable well-being of each resident for 1 of 1 nursing staff reviewed for nursing services. The facility did not provide evidence that LVN E was competent and received training on resident care plans and implementing care according to care plans.This failure could place the residents at risk for not receiving required care, complications, injury, hospitalization, and decline in conditionFindings included:During an interview on 1/7/2026 at 3:20PM LVN E stated she did not know how to read care plans. LVN E stated she had not received training in reading or implementing care plans. LVN E stated she had worked at the facility for 7 years. LVN E stated she knew the care plans were located in Point Click Care. LVN E stated the risk of not knowing how to read care plans could result in improper care and not meeting resident needs.During an interview on 1/7/2026 at 3:10 p.m., the MDS Coordinator said the staff have been in-serviced on care plans and there were monthly meetings. He stated he developed care plans according to the assessments completed. During an interview on 1/7/2026 at 4:00PM with the DON, she stated staff were trained in reading and implementing care plans. She stated the MDS Coordinator and herself developed and updated the care plans as needed. She stated the risk of a nurse not knowing how to read a care plan could be resident needs not being met.During an interview on 1/17/2026 at 4:30 p.m., the Administrator said staff were expected to know how to read and implement care plans. She stated she thought LVN E had worked here at least 5 years or more. The risk if staff were not competent in reading and implementing care plans could be a decline in condition.Record review of an in-service titled transfer techniques with no date was provided by the DON and revealed that was the care plan training nurses received. This in-service did not include LVN E.Record review of facility policy titled Comprehensive Care Plan dated 4/25/2021 revealed:Every resident will have an individualized interdisciplinary plan of care in place. The care plan is revised every quarter, significant change of condition, annual or as the resident condition changes on an individualized basis. The care plan process is an ongoing review process. The resident's Care Plan will include participation from residents, representatives, external partners, hospice, therapy, clinicians and not all-inclusive.

Based on interview and record review, the facility failed to develop, implement, and maintain an effective training program for all new and existing staff for 5 of 27 (CNA A, CNA B, LVN C, CNA D, and LVN E) employees reviewed for disaster training requirements. CNA A, CNA B, LVN C, CNA D, and LVNE were not adequately trained in emergency preparedness training related to bomb threats. This failure could result in delayed or inappropriate response in the event of a bomb threat.The findings included:Resident #3Review of Resident #3's admission Record, dated 12/2/25, indicated he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including paraplegia, pressure ulcer to the sacral region, neuropathy and above the knee amputation of both legs. Resident #3 was discharged [DATE]. Review of Resident #3's Quarterly MDS, dated [DATE], indicatedHe had a BIMS score of 13 of 15 (indicating he was cognitively intact) and he showed no signs of delirium.He reported no symptoms of depression.There were no behaviors reported. Review of Resident #3's Care Plan, updated 6/11/25, documented:Resident had a behavior problem related to low frustration tolerance. Identified interventions included - Anticipate and meet the resident's needs;- if reasonable discuss the resident's behavior, explain/ reinforce why behavior was inappropriate and/or unacceptable to the resident. Review of Resident #3's Care Plan, updated 10/12/24 (previous visit), documented:Focus: The resident had the potential to be verbally aggressive (cursing, yelling at staff) related to ineffective coping skillsGoal: The resident will demonstrate effective coping skills through the review date.Interventions:- Administer medications as ordered;- Analyze of key times, places, circumstances, triggers, and what de-escalates behavior and document.- When the resident becomes agitated: Intervene before agitation escalates. Guide away from source of distress. Engage calmly in conversation; if response is aggressive, staff walk calmly away, and approach later. Interview on 12/2/25 at 12:23 p.m. CNA A stated she was at the nurse's station between 8 a.m. and 8:15 a.m. and Resident #3 approached her. CNA A stated Resident #3 told her he received an eviction notice and wheeled away. CNA A said then Resident #3 rolled up to her laughing; CNA A asked why he was laughing and Resident #3 stated when he got out of here he would shoot up or bomb this shit hole. CNA A stated she was at a loss for words and said, oh, okay. CNA A said she waited for a statement like 'just kidding' but Resident #3 did not say anything. CNA A said it was like Resident #3 was joking but not joking and there was no eye contact when he said it, like he was really thinking about it. CNA A stated the nurse next to her did not hear it. CNA A said she told her nurse about it and the nurse instructed her to report to the Administrator. CNA A said someone told the DON, the ADON, and the SSD and she told them what happened. CNA stated the Administration called the police and the police asked her if she wanted to press charges. CNA A stated she thought Resident #3 was very capable of following through with the threat if he was back on drugs. CNA A said she could see Resident #3 was fantasizing about it, daydreaming about it. CNA A stated she had no idea to ask where he would put it because it was the first time anyone said something like that to her. CNA A stated the training she received on disaster preparedness was the computer training and it kind of run through what to do with a bomb threat. CNA A said the last time she received training on what to do in case of a bomb threat was when there was a suspicious package across the street, but the police told them to shelter in place. CNA A stated the facility went over the situation in the next town hall meeting, but it was just the facility did what they had to do, it was very quick and just covered the staff moved the residents to safety. CNA A stated if she answered the phone and someone said there was a bomb in the building she would give the phone to the nurse. CNA A said she would then tell the other nurse so they could get a hold of the DON or ADON. CNA A said she wouldn't even know what to do. CNA A stated she read the policy and passed it on to the next person. CNA A stated she did not remember what disaster training went over a bomb threat at this or any other facility she worked at previously; CNA A said she only knew the order of evacuation and what to do in case of a fire. CNA A stated she did not feel the facilities went over it as much as fire preparation. Interview on 12/2/25 at 1:27 p.m. CNA B stated if she answered the phone and someone said there was a bomb in the building the training she got was to not panic, notify whoever was around to notify authorities and call administration. CNA B said she was told to keep the caller talking and ask questions. CNA B said she did not want to ask the caller the location of the bomb because she did not want to trigger them. CNA B said she would ask the caller what they wanted, what their intentions were, and keep them on the line as long as possible, distracted. After prompting by surveyor, CNA B said she would listen for background noises to try and determine where they were calling from. CNA B said the last training she received on what to do in a bomb threat was the previous year in another facility. CNA B said she was not worried about if someone called in because it would come to her. Interview on 12/2/25 at 2:34 p.m. LVN C stated he never saw Resident #3 be physical but he would yell a lot and push residents in wheelchairs to the side of the hall so he could get through. LVN C described Resident #3 as me first, now type of resident. LVN C said the aides would report he cussed them out a lot, but LVN C never saw it. LVN C stated he answered the phones. LVN D said if someone told him there was a bomb in the building he would uhh. alert the DON, ADON, police department, and get everyone out of the building. LVN C stated if a resident said they wanted to blow up the building, LVN C would ask why and what he could do to make them not want to blow up the building. LVN C said he did not know what he would do. LVN C stated he probably got training for a bomb threat but forgot it. Interview on 12/2/25 at 3:22 p.m. CNA D stated she worked with Resident #3, she described him as always angry with the world. CNA D stated he told LVN E 'how would you like it if I bombed this place', but it was to LVN E. CNA D said Resident #3 would blow up for no reason. CNA D said if someone told her there was a bomb in the building she would ask where it was. CNA D stated she believed Resident #3 would tell her. CNA D said there was no reason for Resident #3 to say he wanted to blow up the building. CNA D said if she answered the phone and someone said there was a bomb in the building she would call 9-1-1 from another phone and write to the nurse to go look for the bomb. CNA D said she was never in that situation. CNA D said she never had disaster training in any building she worked in, and she did not know who was supposed to go look for the bomb or who was responsible for getting the residents out of the building. CNA D admitted she did not know what she would do. Interview on 12/2/25 at 4:31 p.m. LVN E stated Resident #3's behavior depended on the day. LVN E said on the bad days, Resident #3 would flip out, throw things, refuse wound care, yell, complain about little things, and use rude hand gestures. LVN E stated the only threatening thing Resident #3 said was these bitches will get what's coming to them and then he would be all apologetic. LVN E denied Resident #3 said he would blow up the building to her. LVN E said if a resident told her they wanted to blow up the building she would call 9-1-1 immediately and then call the DON, Administrator and SSD. LVN E said there was also a number at the nurse's station for the local psychiatric hospital. Interview on 12/3/25 at 9:44 a.m. LVN F stated she was sitting next to CNA A and Resident #3 when Resident #3 made the bomb threat. LVN F said she did not know how she did not hear it; LVN F said she could hear they were talking but not what they were talking about. LVN F knew the process for what to do if someone called in a bomb threat. Interview on 12/3/25 at 12:47 p.m. the VPO said in case of a bomb threat, he expected his staff to keep the caller on the phone for as long as possible and get as much information as possible. The VPO said he expected the staff to flag down someone else to initiate calls to the local authorities, the administration, and evacuate the area if possible. The VPO stated he expected staff to follow the directions of the Administration. The VPO stated what to do in case of a Bomb Threat should be in the Disaster Preparedness book, the book should be available to everyone, and the default place for it was usually the nurse's station. The VPO stated the minimum requirement for Disaster Preparedness training was annually, but he expected the staff to be in-serviced as things came up. The VPO stated he expected staff to debrief with the Administration and just make sure the residents were safe. The VPO stated there was real-life situation at the facility, but the police told the facility to just shelter-in-place. The VPO stated the facility did drills on what to do in a disaster, but it was usually fire drills. Interview on 12/3/25 at 2:13 p.m. the DON stated if someone called in a bomb threat her expectation was the staff keep the caller on the line for as long as possible the flag someone else down to notify the police department and the Administration. The DON stated she expected the staff to try and get as much information as possible like who was the caller, where was the bomb, what kind of bomb was it. After prompting the DON stated the staff needed to be listening for background noise. The DON stated hopefully the police department got there quickly. The DON said if they could find out where the bomb was the facility could evacuate that part of the facility threatened. The DON stated the facility trained the staff in bomb threats twice a year but since there was the bomb scare in August 2025 they try to do the training a little more often. Interview on 12/3/25 at 3:52 p.m. the SSD stated Resident #3 was ok when the Administration was in the building but after hours he would be disrespectful and yell at the staff, especially the aides. The SSD stated the aide came to her and said Resident #3 made a bomb threat, so she let the case managers and Administrator know. The SSD said the facility called the police department and the police officer did speak with Resident #3. The facility requested a mental health screening and the Resident #3 denied making the statement, and that it was just a joke to the mental health screener. The SSD said she thought the switch in Resident #3's behavior was triggered because he had to make payments to the facility to stay there. Interview on 12/4/25 at 11:44 a.m. the Administrator stated the facility in-serviced staff on what to do in case of a bomb threat. Interview on 12/4/25 at 12:45 p.m. the Administrator stated the facility had town hall meetings informing the staff what to do in case of a bomb threat and none of the staff came to the management and stated they were not sure what to do. Review of the in-service, dated 9/22/25, documented the DON in-serviced 36 staff on restraints (physical and chemical), sharps and hazardous chemicals, and Egress and disaster preparedness. Review of the in-service, dated 11/17/25, documented the DON in-serviced staff on the smoking policy and bomb threats: exact time and date, keep calm, keep talking, ask when and where, notify appropriate personnel. 33 staff attended. Review of the facility's Emergency Procedure on Bomb threats, undated, documented Utilize the Bomb Threat Telephone Checklist if telephone threats or warnings about bombs in the facility are received. Try to keep the caller on the phone if possible. A separate staff member will initiate the call to 9-1-1. Make the following announcement: Code Yellow. Assigned staff please report to (location) for instructions.Notify the following Executive Director and/or the highest ranking staff member on duty.Do not approach or touch a suspicious package/device. Immediately evacuate everyone away from such discoveries and immediately report all findings to the Executive Director.It is essential to coordinate all actions with law enforcement officials. If a suspected bomb is located within the building, the responsibility for investigation will be that of the law enforcement officials having jurisdiction over such matters.Telephone Procedure:Keep the caller on the line if possibleAsk the caller to repeat the message.Record every word spoken by the person making the call.Record the time the call was received and terminated.Ask the caller his/her nameIf the caller does not indicate the location of the bomb or detonation time, the person received the call should ask the caller to provide this information.It may be advisable to inform the caller that the building is occupied and that the detonation of a bomb could result in death or serious injury to many innocent people.Completed the Bomb Threat Telephone Procedure Checklist. There was no check list provided.

Based on observations, interviews, and record review the facility failed to ensure that a resident who needs respiratory care was provided such care, consistent with professional standards of practice for 6 (Residents #6, #7, #8, #9, #10, and #11) of 6 residents observed for oxygen management. The facility failed to ensure that Residents on oxygen (#6, #7, #8, #9, #10, and #11) had oxygen signs posted outside their bedrooms (Rooms 4, 14, 15, 20, 26, and 33). This failure could place residents on oxygen therapy at risk of receiving incorrect or inadequate oxygen support and decline in health. Findings included: Resident #6Record review of Resident #6's admission record dated 10/10/25, revealed an admission on [DATE] and re-admission on [DATE] to the facility. The admission record revealed, a [AGE] year-old male diagnosed with heart failure and respiratory failure. Record review of Resident #6's MDS dated [DATE], revealed a BIMS score of 3, indicating the resident had severely impaired cognition. The MDS was marked for oxygen therapy. Record review of Resident #6's order summary dated 10/10/25, revealed oxygen via nasal cannula at 2 liters per minute to maintain SpO2 (blood oxygen level) greater than 90% as needed for shortness of breath. Record review of Resident #6's care plan dated 08/08/25, revealed oxygen therapy via nasal cannula at 2 liters per minute to maintain SpO2 greater than 90%. Observation on 10/07/25 at 1:20 PM, revealed Resident #6 was asleep in bed, with nasal cannula on, and oxygen set at 2 liters per minute. No Oxygen Sign was placed outside of Resident #6's room. Resident #7Record review of Resident #7's admission record dated 10/10/25, revealed an admission on [DATE] and re-admission on [DATE] to the facility. The admission record revealed, a [AGE] year-old male diagnosed with heart failure, paraplegia (type of paralysis that affects the lower body) and COPD (chronic obstructive pulmonary disease-a lung condition caused by damage to parts of the lungs).Record review of Resident #7's MDS dated [DATE], revealed a BIMS score of 14, indicating the resident had relatively good cognitive function. The MDS was marked for oxygen therapy. Record review of Resident #7's order summary dated 10/10/25, revealed, may have O2 to keep SpO2 above 92. Record review of Resident #7's care plan dated 07/30/25, revealed O2 at 2 liters per minute per nasal cannula to maintain SpO2 at 93-100%. Observation on 10/07/25 at 1:24 PM, revealed Resident #7 was not in the room, nasal cannula connected to the oxygen port and oxygen set at 2 liters per minute. No Oxygen Sign was placed outside of Resident #7's room. Resident #8Record review of Resident #8's admission record dated 10/09/25, revealed an admission on [DATE] to the facility. The admission record revealed, a [AGE] year-old male diagnosed with heart failure, COPD and nicotine dependence. Record review of Resident #8's MDS dated [DATE], revealed a BIMS score of 11, indicating the resident had moderate impaired cognition. The MDS was marked for oxygen therapy. Record review of Resident #8's order summary dated 10/09/25, revealed oxygen via nasal cannula at 2-6 liters per minute to maintain SpO2 greater than 90% every shift for COPD. Record review of Resident #8's care plan dated 09/12/25, revealed oxygen therapy via nasal cannula at 2-6 liters per minute to maintain SpO2 greater than 90%. Observation on 10/07/25 at 1:26 PM, revealed Resident #8 was in bed watching television, with nasal cannula on, and oxygen set at 3.5 liters per minute. No Oxygen Sign was placed outside of Resident #8's room. Resident #9Record review of Resident #9's admission record dated 10/10/25, revealed an admission on [DATE] to the facility. The admission record revealed, an [AGE] year-old female diagnosed with heart failure, pulmonary fibrosis (a lung disease that causes scarring and thickening of lung tissue) and respiratory failure. Record review of Resident #9's MDS dated [DATE], revealed a BIMS score of 13, indicating the resident had relatively good cognitive function. The MDS was marked for oxygen therapy. Record review of Resident #9's order summary dated 10/10/25, revealed oxygen via nasal cannula at 2 liters per minute to maintain SpO2 greater than 90% as needed for shortness of breath. Record review of Resident #9's care plan dated 10/08/25, revealed oxygen therapy via nasal cannula at 2 liters per minute to maintain SpO2 greater than 90%, due to poor oxygen absorption. Observation on 10/07/25 at 1:40 PM, Resident #9 was in bed, with nasal cannula on, and oxygen set at 2 liters per minute. No Oxygen Sign was placed outside of Resident #9's room. Resident #10Record review of Resident #10's admission record dated 10/09/25, revealed an admission on [DATE] to the facility. The admission record revealed, an [AGE] year-old male diagnosed with COPD, pulmonary fibrosis and respiratory failure. Record review of Resident #10's MDS dated [DATE], revealed a BIMS score of 7, indicating the resident had severely impaired cognition. The MDS was marked for oxygen therapy. Record review of Resident #10's order summary dated 10/09/25, revealed oxygen via nasal cannula at 2-6 liters per minute to maintain SpO2 greater than 90% as needed for pulmonary fibrosis. Record review of Resident #10's care plan dated 10/08/25, revealed oxygen therapy via nasal cannula at 2-6 liters per minute to maintain SpO2 greater than 90%. Observation on 10/07/25 at 1:44 PM, revealed Resident #10 was asleep in bed, with nasal cannula on, and oxygen set at 2 liters per minute. No Oxygen Sign was placed outside of Resident #10's room. Resident #11Record review of Resident #11's admission record dated 10/09/25, revealed an admission on [DATE] and re-admission on [DATE] to the facility. The admission record revealed, a [AGE] year-old female diagnosed with heart disease and COPD.Record review of Resident #11's MDS dated [DATE], revealed a BIMS score of 14, indicating the resident had relatively good cognitive function. The MDS was marked for oxygen therapy. Record review of Resident #11's order summary dated 10/09/25, revealed oxygen via nasal cannula at 2-4 liters per minute to maintain SpO2 greater than 90% as needed for COPD. Record review of Resident #11's care plan dated 08/06/25, revealed oxygen therapy via nasal cannula at 2-4 liters per minute to maintain SpO2 greater than 90%. Observation on 10/07/25 at 1:47 PM, revealed Resident #11 was in bed, with nasal cannula on, and oxygen set at 2 liters per minute. No Oxygen Sign was placed outside of Resident #11's room. During an interview on 10/10/25 at 12:45 PM with the DON, she said there was not a designated staff member responsible for placing the oxygen signs on the doors when a resident was on oxygen. The DON said that the lack of oxygen signs on the appropriate doors could cause injury to the residents and the staff. During an interview on 10/10/25 at 1:10 PM with the administrator, she said she was under the impression that signs on individual resident doors was not required because the facility has a sign at the front entrance. Regarding the facility oxygen policy, the administrator said she was not aware that the policy said a sign needs to be placed outside the rooms of residents using oxygen. Record review of the facility Oxygen Therapy policy dated 04/2021, revealed, Post NO SMOKING sign on the outside of door to resident's room.

Based on observation, interview, and record review the facility failed to ensure that residents environment remained as free of accidents and hazards as possible, and each resident received adequate supervision to prevent accidents for 1 (Resident #7) of 5 residents reviewed for transfers. The facility failed to ensure Resident #7 had floor mat at bedside when in bed to prevent falls with injury that occurred on 05/12/2025. This failure could place residents at risk for falls or injuries. Findings included: Record review of Resident #7's face sheet dated 5/14/25 revealed a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses that included: cerebrovascular disease, meaning he has problems with blood flow in the brain, which can lead to strokes or damage to brain tissue; seizures, which are sudden episodes of uncontrolled electrical activity in the brain that can cause shaking or confusion; psychotic disorder caused by a medical condition, meaning he may have false beliefs or see things that aren't real due to brain-related illness; substance dependence in remission, indicating a past drug or alcohol problem that is currently under control; generalized anxiety disorder, which causes ongoing and excessive worry, and major depressive disorder, a condition involving long-lasting and severe sadness; unspecified lack of coordination, meaning he struggles with balance and movement control; generalized muscle weakness makes it harder for him to move, stand, or walk; rhabdomyolysis, a serious muscle condition where broken-down muscle fibers can damage the kidneys; mild cognitive impairment affects his memory and thinking skills, though not severely enough to be classified as dementia; stroke caused by a blood clot in the brain, which may have resulted in weakness or confusion; muscle wasting in both lower legs, meaning he has lost muscle tissue, making his legs weaker and thinner; lack of coordination, indicating further difficulties with controlled movements and balance. Record review of Resident #7's annual MDS assessment dated [DATE] revealed a no BIMS score (indicative of severe cognition impairment) noted and his was triggered for falls. Record review of Resident #7's care plan dated 5/7/25 revealed a focus area for history of falls that included interventions for low bed to decrease incidents of falls, fall mat at bedside when in bed. Record review of Resident #7's progress note dated 5/2/25 written by LVN B revealed [Resident #7] fell out of bed, landing on fall mat but got a 5cm laceration/bump to left forehead that is tender to touch. Cleansed laceration and pat dry, placed steri-strips. Denies any other c/o pain or discomfort. [Resident #7] moves leftt upper and lower ext. WNL. VS-123/61, 63, 18, 97.5, 97% on RA. Assisted back to bed x3 staff. Physician, DCO, ADCO, and Admin notified. Placed call to family, no answer, unable to leave message. Record review of Resident #7's local hospital discharge summary dated 5/2/25 revealed diagnoses of traumatic hematoma of forehead and neck pain. No nre orders were noted and only instruction provided was to follow up with physician within 2-4 days. Record review of Resident #7's CT Cervical Spine without contrast dated 5/2/25 revealed Clinical Information: Patient evaluated due to trauma. Findings: No fracture, dislocation, or prevertebral soft tissue swelling. Mild osteopenia (low bone density). Diffuse degenerative changes throughout cervical spine. Impression: No fracture or dislocation. Degenerative spinal changes, especially at C5-C6, with narrowing in several nerve pathways (foramina) and central canal. Diffuse skeletal wear and tear. No major changes compared to the last scan on December 20, 2023. Record review of Resident #7's CT Brain/Head without contrast dated 5/2/25 revealed Clinical Information: Patient evaluated for trauma-related concerns. Findings: Moderate-sized anterior subcutaneous hematoma on the left of midline. No acute intracranial abnormalities (no stroke, fluid collection, mass, midline shift, or bleeding). Calcified changes in skull arteries. Mild generalized brain volume loss for age. Chronic small vessel ischemic disease. Old strokes noted in left frontoparietal region and right premotor frontal cortex. Small old infarcts seen in the left basal ganglia. Impression: Moderate anterior subcutaneous hematoma (left of midline). No acute intracranial abnormality. Mild generalized volume loss (age-related). Chronic ischemic changes consistent with age. During an observation and interview on 5/13/25 at 8:57 am, Resident #7 was observed to have a black eye and a hematoma on his left eyebrow . He was AOx2 and stated he had fallen in the facility but could not recall when or where the fall occurred. He reported that he was trying to go to the restroom when he fell . It was noted that his bed was at lowest position and no floor mat was noted at bedside. During an interview on 5/13/25 at 10:43 am, CNA A stated that Resident #7 had been moved to his current room the previous day, with the transfer occurring on Monday (5/12/25). CNA A stated that Resident #7 was a fall risk and should have had a floor mat placed at the bedside. She stated she was unsure why the mat had not been placed and stated she had reported the issue to the nurse, who stated she was looking for it. During an interview on 5/13/25 at 1:32 pm, LVN B stated that Resident #7 fell during her shift at approximately 10:30 AM. LVN B stated she was notified by CNAs while at the nurse ' s station. LVN B stated that upon arriving, she found Resident #7 on the floor mat, with his head off the mat and the left side of his face on the floor. LVN B stated the fall was unwitnessed. LVN B stated Resident #7 sustained a laceration to the left forehead. LVN B stated Resident #7 reported pain to the head and later stated his neck was hurting. LVN B stated Resident #7 is on aspirin and Eliquis. LVN B stated she assessed Resident #7, checked his vitals, turned him on the mat, asked about pain, and assisted him back to bed. LVN B stated neuro checks were initiated. LVN B stated she reported the fall to the DCO and ADCO and faxed a report to the physician. LVN B stated no new orders were received. LVN B stated Resident #7 was eventually sent out to the hospital the same day and returned after her shift without sutures or new orders. During an interview on 5/13/25 at 2:31 pm, CNA C stated she had just completed changing and repositioning Resident #7, placing the bed in a low position with the fall mat in place on day of the incident (5/2/25). CNA C stated that while conducting rounds, she heard Resident #7 calling for help. CNA C stated that upon responding, she found Resident #7 on his stomach, with his left side and face on the floor and his head partially under the bed frame. CNA C stated she lifted the bed and spoke to Resident #7 while calling for additional assistance. CNA C stated she notified the nurse, LVN B, that Resident #7 was bleeding from the head. CNA C stated she extended his legs out with permission from LVN B. CNA C stated she noted visible swelling and a bulge at the injury site. CNA C stated the CNAs transferred Resident #7 to bed with LVN B ' s direction. CNA C stated Resident #7 did not initially express pain but later began verbalizing head pain. During an interview on 5/13/25 at 3:07 pm, the ADCO stated that fall prevention measures included keeping the bed in the lowest position, placing a fall mat at the bedside, and ensuring the call light was within reach. The ADCO stated that charge nurses and aides conducted routine rounds, and department heads completed morning room checks. The ADCO stated that failure to have floor mat at bedside, Resident #7 was at risk for injury related to falls. During an interview on 5/13/25 at 4:23 pm, the DCO stated that the facility's fall prevention measures included bed positioning, floor mats, and accessible call lights. The DCO stated that staff completed regular rounds and room checks to ensure fall preventions were followed and stated that Resident #7 was at risk for fall-related injury due to not having floor mat at bedside. The DCO stated staff received training regarding fall precautions on a daily basis. DCO stated that Resident #7 was a known frequent faller. DCO stated that fall precautions in place included use of a low bed, floor mat, and frequent rounding by CNAs, housekeeping, and nurses. DCO stated the mat is placed when Resident #7 is in bed. DCO stated she walks the halls daily to ensure fall prevention practices are being followed. DCO stated she attempts to review fall precautions at least monthly. DCO stated the identified risk was injury related to falls. DCO stated Resident #7 was moved to a different hallway where a bed was available closer to the nurses station for increased monitoring. During an interview on 5/13/25 at 5:56 pm, Dr. stated he had been notified about Resident #7 ' s fall on May 2, 2025, by fax, phone call, or text, though he was unable to recall the exact method due to the volume of communications from the facility. Dr. stated that when a resident falls, the standard protocol is to assess whether they are stable. Dr. stated that if the bleeding has stopped and the resident remains conscious, the recommendation is typically to monitor. Dr. stated that if the resident is unconscious or the bleeding is persistent, immediate transfer to the hospital is warranted. Dr. stated that Resident #7 sustained a laceration to the head and had complained of pain. Dr. stated steri-strips were reportedly changed three times prior to Resident #7 being sent out. Dr. stated that in cases involving anticoagulant use, such as Eliquis, taken the morning of the fall, a resident with worsening or significant pain would generally be expected to be transferred within a few hours. Dr. stated that judgment is based on the presence or absence of concerning symptoms at the time. Dr. stated that Resident #7 underwent CT scans of the brain and cervical spine while at the hospital. Dr. stated the brain scan showed a subcutaneous hematoma without evidence of intracranial bleeding. Dr. stated the cervical spine scan did not show fractures or dislocation but did show chronic osteoarthritis, which may contribute to balance issues. Dr. stated laboratory results did not indicate anemia, infection, or kidney dysfunction, and Keppra levels were not in the toxic range. Dr. stated that Resident #7 is at high risk for falls and should be monitored closely. Dr. stated that floor mats can sometimes help but may also pose a tripping hazard depending on the resident ' s behavior. Dr. stated the use of such interventions should be evaluated individually. Dr. stated that there were no serious findings from the hospital evaluation and that the injuries appeared to be superficial, with no immediate complications identified. During an interview on 5/14/25 at 11:27 am, The Administrator stated she received a report that Resident #7 was being provided a new mattress because the previous one was soiled. The Administrator stated all staff to include CNAs, nurses, and management were responsible for ensuring fall prevention measures were in place and followed during their daily rounds. The Administrator stated all staff received training on fall prevention at least monthly by the DOC. The Administrator stated potential risk for not having floor mat at bedside when in bed could be fall with injury. Record review of the facility's Incident and Accident policy dated 03/01/2017 revealed 11. A fall prevention program will be initiated. The program will be reviewed with any subsequent falls. All programs will be documented in the plan of care and updated with each new fall.

Based on interviews, and record review, the facility failed to incorporate recommendations from a PASRR (Preadmission Screening and Resident Review) evaluation report into a resident assessment, care planning, and transition of care for 1 (Resident #4) of 3 residents reviewed for PASRR services. The facility failed to submit a complete and accurate request for NFSS in the LTC online portal within 20 days after the IDT meeting. This failure could place residents who were PASRR positive at risk of not getting the PASARR services for a better quality of life and could lead to a decline in health. Findings included: Record review of Resident #4's face sheet dated 5/13/25 revealed a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses that included: contracture of an unspecified joint (a joint that has become stiff and difficult to move) and contracture of muscle, unspecified site (a tightening of muscles that limits movement); generalized muscle weakness (overall reduced strength throughout the body) and muscle wasting and atrophy, multiple sites (loss of muscle tissue in several areas, leading to weakness); other lack of coordination (trouble controlling body movements), scoliosis (an abnormal curve of the spine), and reduced mobility (difficulty walking or moving around independently); encephalopathy (a type of brain dysfunction caused by another illness or imbalance in the body), unspecified lack of coordination (difficulty moving smoothly due to problems in the brain or nervous system), and dysphagia in the oropharyngeal phase and unspecified (trouble swallowing food or liquids); profound intellectual disabilities (significant limitations in mental functioning and daily living skills), epilepsy, unspecified (a seizure disorder), cerebral palsy (a condition that affects muscle movement and coordination, often from birth), and hemiplegia, unspecified side (paralysis on one side of the body, though the side is not specified). Record review of Resident #4's quarterly MDS assessment dated [DATE] revealed no BIMS score was noted but was marked as moderately impaired under the cognitive skills for daily decision making. Record review of Resident #4's PASRR Level 1 Screening Summary dated 10/16/24 revealed a positive response for a known or suspected diagnosis of intellectual disability. Record review of Resident #4's PASRR Evaluation dated 10/17/24 revealed he was identified as having an intellectual disability and requires specialized services. Record review of Resident #4's PCSP dated 1/22/25 revealed IDT meeting was held on 01/22/2025. Attendees included the resident, the PASRR habilitation coordinator, a social worker, PTA, RD/PTA, and nursing facility representatives. The following NFSS were identified and confirmed: Durable Medical Equipment. The Comments summary revealed the resident will continue PASRR habilitation coordination services. The family expressed interest in obtaining a CMWC and mattress, which were delayed pending Medicaid activation. The Local Authority for IDD confirmed the selected specialized services. During an interview on 5/14/25 at 10:18 am, the CRC stated Resident #4 was admitted on [DATE]. The CRC stated he did not have access to all PCSPs on his end, only the most recent dated 5/5/25. The CRC stated an initial care plan meeting was held with participation from himself, rehabilitation, the director, activities, dietary, and the local PASRR Coordinator, along with Resident #4 and their family. The CRC stated the local PASRR Coordinator offered services including assistance from the State of Texas such as gate assistive devices, a car seat, and other miscellaneous items. The CRC stated the facility provided input regarding Resident #4's low-income status and explained that the current wheelchair had been used for an extended period. The CRC stated a customized wheelchair was offered and accepted by Resident #4 and their family. The CRC stated he contacted the local PASRR Coordinator by phone, and she agreed to send the January PCSP, as it was not accessible to him. The CRC stated the local PASRR Coordinator informed him that the January PCSP was pending due to Medicaid status, which had remained pending since admission. The CRC stated the wheelchair request remained pending and under state review. The CRC stated the PCSP must align with the completion of an NFSS form, which must be submitted by the administrator, physician, and director of rehabilitation. During an interview on 5/14/25 at 10:41 am, the DOR stated the NFSS for Resident #4 was initially submitted on 4/25/25 but was declined because an assessment was not associated with the submission. The DOR stated the physician's signature date could not precede the therapist's signature. The DOR stated the NFSS was resubmitted on 4/30/25 and was currently pending receipt and under state review. The DOR stated she was previously unaware of this status and understood that the state has up to 20 days to complete review. The DOR stated she was uncertain what type of wheelchair Resident #4 was currently using but confirmed it did not meet his needs. During an interview on 5/14/25 at 11:27 am, the Administrator stated she was familiar with the PASRR process and that the NFSS is completed by the DOR and should be submitted within two weeks. The Administrator stated that during the transition period in January, only four therapists were available, and some submissions may have been overlooked. The Administrator stated the current full-time DOR, began employment last month and had been addressing pending submissions. Record review of the facility's PASRR policy dated 11/2023 revealed Follow Texas PASRR Policy for all mandatory meetings and care coordination including any changes that may require a change in resident's PASRR status. Record review of state agency website https://www.hhs.texas.gov/regulations/forms/2000-2999/form-2362-receipt-certification-a-qualified-rehabilitation-professional revealed: Requesting Habilitative Services: A speech, occupational or physical therapist may request habilitative therapies (physical, occupational or speech therapy) for a PASRR-positive person for up to 6 months at a time. Requests for Authorization of Specialized Services for Residents of Nursing Facilities Requesting Authorization of Habilitative Physical, Occupational or Speech Therapy. To request Habilitative therapies, nursing facility providers must submit a Nursing Facility Specialized Service (NFSS) form on the Texas Medicaid and Healthcare Partnership (TMHP) Long Term Care (LTC) Online Portal. Additionally, each request must be accompanied by corresponding signature sheets or other attachments. A licensed therapist must complete and submit the following for each type of habilitative therapy service requested. New Request: New (Submit initial assessment). An initial therapy assessment completed by a licensed therapist is required. The service request must include a treatment plan. PASRR NF Specialized Services (NFSS) - Therapy Signature Page (for Therapist, Referring Physician and Nursing Facility Administrator signatures).

Based on observation, interview, and record review the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 3 (Resident #6) residents reviewed for infection control. The facility failed to ensure Resident #6 had a contact isolation on her door alerting visitors she was in isolation related to shingles. This failure could place residents at risk of cross contamination which could result infections or illness. Findings include: Record review of Resident #6's face sheet dated 5/13/25 revealed a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses that included: seizures, including those caused by fever, and has episodes of uncontrolled body shaking without a clearly identified cause; poor coordination, which affects her ability to move steadily and may lead to clumsiness or difficulty walking; aphasia, a condition that impacts her ability to speak and comprehend language, often linked to brain damage; anxiety and psychosis, which can include confusion, hallucinations, or delusions, along with schizoaffective disorder, a condition involving both mood swings and symptoms similar to schizophrenia. Record review of Resident #6's annual MDS assessment dated [DATE] revealed she did not have a BIMS score but her cognitive skills for daily decision was marked as severely impaired. Record review of Resident #6's care plan dated 5/8/25 revealed a focus area for current skin concerns: rash to left and middle forehead; identified as shingles 5/8/25 - placed on isolation. Record review of Resident #6's physician order dated 5/8/25 revealed Valtrex oral tablet 1GM, give 1 tablet via peg-tube two times a day for shingles. Record review of Resident #6's progress note dated 5/8/25 written by DCO revealed [Resident #6] moved to isolation at this time. During an observation on 5/13/25 at 9:10 am, Resident #6 was noted to have PPE located outside of her room, but there was no signage posted indicating that she was under isolation precautions. During an interview on 5/13/25 at 9:30 am, LVN B stated that Resident #6 had been placed in isolation the previous week due to blisters on her forehead, which were identified as shingles. She stated that the resident was under contact precautions but there was no sign posted at the door to alert visitors or staff. She stated that she had noticed the missing signage but had not reported it to anyone. She stated that nursing administration would have been responsible for ensuring signage was posted. She stated that the lack of signage posed a risk, as visitors could unknowingly enter the room without PPE, potentially exposing themselves to infection. She stated that lab technicians and X-ray staff typically arrived in the early morning and reported to the charge nurse, who would then escort them to the resident's room. During an interview on 5/13/25 at 3:07 pm, the ADCO stated that she served as the infection preventionist nurse and that Resident #6 had been on contact isolation for shingles since the previous Thursday. She stated that there should have been signage on the door and noted that the resident had been moved late Thursday. She stated that she had not yet completed rounds in that area. She stated that the absence of signage posed a risk of transmission and cross-contamination. During an interview on 5/13/25 at 4:23 pm, the DCO stated that Resident #6 was on isolation precautions for shingles and should have had appropriate signage and PPE setup outside her room. She stated that the ADCO was responsible for ensuring that isolation precautions were implemented. She stated that all direct care staff were expected to follow enhanced barrier precautions, including the use of gowns and gloves during activities such as dressing and perineal care. She identified the risk as potential transmission of infection. During an interview on 5/14/25 at 11:27 am, the Administrator stated that Resident #6 was in isolation for shingles. She stated that signage was posted on the door and that PPE was in place. She stated that the ADCO was responsible for monitoring compliance with isolation protocols. She stated that infection control training was conducted upon hire, monthly, and as needed. She identified contact transmission as the main risk .

Based on interview and record review the facility failed to report an alleged violation of injury of unknown origin immediately to the administrator of the facility and to other officials (including to state survey agency) in accordance with State law and according to their policy for 1 (Resident # 3 ) of 2 residents reviewed for allegations of abuse. The facility failed to report Resident #3 's allegation of abuse related to LNV C's alleged withholding of medication to State Office. This failure could place all residents at risk for abuse and/or neglect by not immediately reporting allegations of abuse to the proper authorities at the facility. Findings Include: Record review of Resident #3's face sheet dated 5/14/25 revealed a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses of generalized anxiety, schizophrenia, and bipolar disorder. Record review of Resident #3's quarterly MDS assessment dated [DATE] revealed a BIMS score of 14, indicating his cognition was intact. Record review of Resident #3's care plan dated 3/19/25 revealed a focus area for resident has a behavior problem r/t low frustration tolerance, bipolar disorder, Schizophrenia with interventions that included Intervene as necessary to protect the rights and safety of others. Approach/Speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed. Record review of LVN C's facility's Disciplinary Action Record dated 3/25/25 revealed nurse observed speaking loud and harshly to [Resident #4]. [Resident #3] complained as well. It was a verbal warning signed by ADCO and team member signature was blank. During an interview on 5/13/25 at 11:10 am, Resident #3, who was AOx4, stated that he felt he was abused when LVN C had not wanted to administer his medication after he returned from the hospital and missed his evening dose. Resident #3 stated that he was asking for an inhaler, as he knew it was scheduled, though he could not recall experiencing symptoms at the time. Resident #3 stated that LVN C had told him it was past the scheduled hour window. Resident #3 stated that he contacted the administrator and reported that he felt abused because of the situation . Resident #3 stated that he was later informed the facility had reached out and was waiting for the physician's approval, and that he received the inhaler shortly after. Resident #3 stated that LVN C was written up but refused to sign the corrective action. Resident #3 stated the facility responded by removing LVN C from his direct care, and that he felt safe afterward. During an interview on 5/13/25 at 2:14 pm, LVN C stated that the facility had recently reassigned care on that hall from himself to another nurse due to Resident #3's repeated complaints and the facility's efforts to accommodate his preferences. LVN C stated an instance when Resident #3 returned from the hospital and requested medication that was scheduled for a later time. LVN C stated that Resident #3 became upset and agitated. LVN C stated that the medication in question was a breathing treatment, which required clearance from the doctor, and that Resident #3 was not presenting with respiratory symptoms. LVN C stated that the treatment was administered after his shift, during shift change. During an interview on 5/13/25 at 3:07 pm, the ADCO stated that she had not received recent complaints regarding LVN C. The ADCO stated that there was a past incident involving Resident #4 and LVN C, which resulted in a corrective action/write-up that was not signed by LVN C. The ADCO stated she had not been present during the incident and referred such matters to administrative leadership. The ADCO stated that a few staff had commented on LVN C's harsh tone. She stated that LVN C was removed from Resident #3's care following the incident. During an interview on 5/13/25 at 4:23 pm, the DCO stated there had been an incident involving LVN C and Resident #3. The DCO stated the issue stemmed from an argument regarding medication administration after Resident #3 returned late from the hospital and requested his 7 or 8 p.m. medication, which LVN C allegedly had declined to administer. The DCO stated that the Administrator had notified her of the incident in which she texted the nurse practitioner regarding the matter to get further instruction. The DCO stated that LVN C was removed from caring for Resident #3 following the incident. The DCO stated that no complaints had been received about LVN C using inappropriate language. The DCO stated he was not suspended and that the action taken was a write-up for speaking loudly and harshly to the resident. The DCO stated she could not speak to administrative decisions and that further details would be handled by leadership. During an interview on 5/14/25 at 11:27 am, the Administrator stated that no recent complaints had been received regarding LVN C. She stated she had instructed LVN C to stop caring for Resident #3 after observing tension and hearing from Resident #3 that LVN C was not performing his duties. She stated that Resident #3 had texted and called her around 10:00-10:20 p.m. to report that LVN C refused to give him his high inhaler medication. She stated that she determined LVN C's shift had already ended and the medication window had been scheduled for 5:00 p.m. She stated that LVN C had explained the missed dose and told Resident #3 about the situation. She stated that she planned for the DCO to follow up with the physician. She stated that she did not consider the incident to be abuse and that Resident #3 later apologized. She stated that the incident was not reported as abuse because there were no staff corroborations and she concluded that it was a misunderstanding, influenced by Resident #3's history of misusing the term abuse. She stated that she did not suspend LVN C, as the incident occurred after his shift ended, and the intervention of removing him from Resident #3's care was completed prior to his next scheduled shift. Record review of the facility's Abuse policy dated 01/01/2023 revealed All events that involve an allegation of abuse or involve a suspicious serious bodily injury of unknown origin must be reported immediately or not later than 2 hours of alleged violation.

Based on observation, interview, and record review the facility failed to ensure a resident, who was fed by enteral means, received the appropriate treatment and services to restore, if possible, oral eating skills and to prevent complications of enteral feeding including but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasal-pharyngeal ulcers for 1 of 3 residents (Resident #6) reviewed for enteral feeding. The facility failed to ensure Resident #6's head of bed was maintained at 30 degrees elevated while receiving continuous feeding. This failure could place residents at risk of aspiration (when food or liquid goes into the lungs or airway). Findings included: Record review of Resident #6's face sheet dated 5/13/25 revealed a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses that included: seizures, including those caused by fever, and has episodes of uncontrolled body shaking without a clearly identified cause; poor coordination, which affects her ability to move steadily and may lead to clumsiness or difficulty walking; aphasia, a condition that impacts her ability to speak and comprehend language, often linked to brain damage; anxiety and psychosis, which can include confusion, hallucinations, or delusions, along with schizoaffective disorder, a condition involving both mood swings and symptoms similar to schizophrenia; gastronomy status, she receives nutrition through a feeding tube placed directly int her stomach. Record review of Resident #6's annual MDS assessment dated [DATE] revealed she did not have a BIMS score but her cognitive skills for daily decision was marked as severely impaired. The nutritional status was marked as her receiving feeding tube. Record review of Resident #6's care plan was dated 5/8/25 revealed a focus area for requires tube feedings related to dysphagia/swallowing problem with interventions that included resident needs the HOB elevated 45 degrees during and thirty minutes after tube feed. Record review of Resident #6's physician order dated 4/18/2018 revealed elevate head of bed at least 30 degrees while administering formula/water/ medications and for at least 30 minutes following administration continuous. During an observation on 5/13/25 at 9:10 am, Resident #6 was observed in bed with the head of bed elevated to 30 degrees, she was nonverbal. However, she was positioned halfway down the mattress with her torso and upper body lying flat. A continuous tube feeding was noted at 32 ml/hr. No signs of distress were observed. During an interview on 5/13/25 at 9:30 am, LVN B stated that Resident #6 had told her she was elevated at approximately 10 degrees. LVN B stated that the resident was elevated to mid-rails to prevent her from falling. She stated that the resident could not get out of bed but was able to turn. She stated there was a risk of aspiration but believed the current elevation was sufficient given the resident's fall risk. She stated that CNAs and nursing staff were responsible during rounds. She could not recall the last time she received training specific to G-tube monitoring related to positioning. During an interview on 5/13/25 at 3:07 pm, the ADCO stated that facility policy requires residents with G-tubes to remain at approximately a 45-degree angle with the head elevated to reduce the risk of aspiration. She stated that this responsibility falls on aides and nurses, and that compliance is reviewed twice a year during rounds. During an interview on 5/13/25 at 4:23 pm, the DCO stated that Resident #6 was on continuous tube feeding and should not be laid flat. She stated that aides and charge nurses were responsible for maintaining the resident's elevation at a minimum of 45 degrees, ensuring that both the head and upper body were elevated, not just the bed. She stated that the resident had a tendency to slide down in bed and should be repositioned regularly to maintain proper alignment . She stated that the risk associated with improper positioning was aspiration and added that training on this topic had not been provided recently. During an interview on 5/14/25 at 11:27 am, the Administrator stated that some residents, including Resident #6, tend to slide down in bed despite repositioning efforts. She stated that residents should still be repositioned at least every two hours. She stated that this task can be performed by CNAs, nurses, or administrative staff. She also stated that training on positioning is included in monthly town hall meetings. Record review of the facility's Administration of Medications via Enteral policy dated 04/2020 revealed there is no direct mention in the provided policy text of residents needing to be positioned at a 30- or 45-degree angle during enteral medication administration or feeding.

Based on observation, interview, and record review the facility failed to maintain medical records on each resident that are accurately documented for 1 (Resident #7) of 6 residents reviewed for accuracy of records. The facility failed to ensure LVN C documented Resident #7's return from the hospital. This failure could have placed residents at risk for inaccurate medical records. Findings included: Record review of Resident #7's face sheet dated 5/14/25 revealed a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses that included: cerebrovascular disease, meaning he has problems with blood flow in the brain, which can lead to strokes or damage to brain tissue; seizures, which are sudden episodes of uncontrolled electrical activity in the brain that can cause shaking or confusion; psychotic disorder caused by a medical condition, meaning he may have false beliefs or see things that aren't real due to brain-related illness; substance dependence in remission, indicating a past drug or alcohol problem that is currently under control; generalized anxiety disorder, which causes ongoing and excessive worry, and major depressive disorder, a condition involving long-lasting and severe sadness; unspecified lack of coordination, meaning he struggles with balance and movement control; generalized muscle weakness makes it harder for him to move, stand, or walk; rhabdomyolysis, a serious muscle condition where broken-down muscle fibers can damage the kidneys; mild cognitive impairment affects his memory and thinking skills, though not severely enough to be classified as dementia; stroke caused by a blood clot in the brain, which may have resulted in weakness or confusion; muscle wasting in both lower legs, meaning he has lost muscle tissue, making his legs weaker and thinner; lack of coordination, indicating further difficulties with controlled movements and balance. Record review of Resident #7's annual MDS assessment dated [DATE] revealed a no BIMS score noted. Record review of Resident #7's care plan dated 5/7/25 revealed a focus area for history of falls that included interventions for low bed to decrease incidents of falls, fall mat at bedside when in bed. Record review of Resident #7's progress note dated 5/2/25 written by LVN B revealed Res. fell out of bed, landing on fall mat but got a 5cm laceration/bump to Lt forehead that is tender to touch. Cleansed laceration and pat dry, placed steri-strips. Denies any other c/o pain or discomfort. Res. moves Lt upper and lower ext. WNL. VS-123/61,63,18,97.5,97% ORA. Assisted back to bed x3 staff. Physician, DCO, ADCO, Admin notified. Record review of Resident #7's progress notes revealed no documentation regarding Resident #7 return from the hospital. During an observation and interview on 5/13/25 at 8:57 am, Resident #7 was observed to have a black eye and a hematoma on his left eyebrow. He was AOx2 and stated he had fallen in the facility but could not recall when or where the fall occurred. He reported that he was trying to go to the restroom when he fell . It was noted that his bed was at lowest position and no floor mat was noted at bedside. During an interview on 5/13/25 at 1:32 pm, LVN B stated that Resident #7 fell during her shift at approximately 10:30 a.m. LVN B stated she was notified by CNAs while at the nurse's station. LVN B stated that upon arrival, she found Resident #7 on the floor mat with his head off the mat and the left side of his face on the floor. LVN B stated the fall was unwitnessed. LVN B stated Resident #7 sustained a laceration to the left forehead. LVN B stated he reported head pain and later stated his neck was hurting. LVN B stated he was on aspirin and Eliquis. LVN B stated she assessed Resident #7, checked vitals, turned him on the mat, asked about pain, and assisted him back to bed. LVN B stated she initiated neuro checks. LVN B stated she reported the fall to the DON, ADON, and faxed a report to the physician. LVN B stated no new orders were received. LVN B stated she attempted to notify the resident's family member , who typically did not answer and did not respond that day. LVN B stated she created the fall note at 1:18 p.m. LVN B stated Resident #7 was sent to the hospital the same day and returned after her shift without sutures or new orders. During an interview on 5/13/25 at 2:14 pm, LVN C stated he was not present during the fall, which occurred during the morning shift. LVN C stated Resident #7 returned during his shift. LVN C stated he was with another patient and did not receive a report or verbal notification of the resident's return. LVN C stated the resident was brought in with paperwork and had a bandage over his eye. LVN C stated Resident #7 denied pain. LVN C stated he was supposed to complete a readmission assessment but likely did not due to a busy shift and communication issues. LVN C stated he understood the expectation was to complete the assessment and that potential risk for lack of documentation could be information being overlooked during high workload periods. During an interview on 5/13/25 at 3:07 pm, the ADCO stated there was no documentation of return time, new orders, or vitals for Resident #7. The ADCO stated staff were required to document these elements. The ADCO stated training was provided monthly and as needed. The ADCO stated leadership reviewed 24-hour reports and compared them with shift reports daily. The ADCO stated some nurses needed improvement, which could impact continuity of care. During an interview on 5/13/25 at 4:23 pm, The DCO stated nurses were expected to document upon a resident's return from the hospital, including any new orders and interventions performed at the hospital. The DCO stated she referred to the 24-hour report process. The DCO stated LVN C failed to chart when Resident #7 returned, and she noticed this the day of the interview. The DCO stated the risk of failing to document was that staff would not be aware of the resident's current condition. The DCO stated quarterly training was conducted to reinforce documentation expectations. The DCO stated the facility did not have a policy on accuracy of documentation. During an interview on 5/14/25 at 11:27 am, the Administrator stated staff were expected to document events as they occurred. The Administrator stated the Director of Clinical Operations had access to the 24-hour report and was expected to ensure follow-through and monitoring. The Administrator stated failure to document accurately could impact continuity of care.

Based on observation, interview, and record review the facility failed to ensure all residents were provided, based on the preferences of each resident, an ongoing program to support residents in their choice of activities, both facility sponsored activities and individual activities, designed to meet the interests and support the physical, mental, and psychosocial well-being of each resident for 1 of 5 (Resident #4) residents reviewed for activities. The facility failed to provide regular, individualized activities to Resident #4. This failure placed residents at risk of decreased physical, mental, and psychosocial well-being. Findings included: Record review of Resident #4's face sheet dated 5/13/25 revealed a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses that included: contracture of an unspecified joint (a joint that has become stiff and difficult to move) and contracture of muscle, unspecified site (a tightening of muscles that limits movement); generalized muscle weakness (overall reduced strength throughout the body) and muscle wasting and atrophy, multiple sites (loss of muscle tissue in several areas, leading to weakness); other lack of coordination (trouble controlling body movements), scoliosis (an abnormal curve of the spine), and reduced mobility (difficulty walking or moving around independently); encephalopathy (a type of brain dysfunction caused by another illness or imbalance in the body), unspecified lack of coordination (difficulty moving smoothly due to problems in the brain or nervous system), and dysphagia in the oropharyngeal phase and unspecified (trouble swallowing food or liquids); profound intellectual disabilities (significant limitations in mental functioning and daily living skills), epilepsy, unspecified (a seizure disorder), cerebral palsy (a condition that affects muscle movement and coordination, often from birth), and hemiplegia, unspecified side (paralysis on one side of the body, though the side is not specified). Record review of Resident #4's quarterly MDS assessment dated [DATE] revealed no BIMS score was noted but was marked as moderately impaired under the cognitive skills for daily decision making. Record review of Resident #4's care plan dated 10/16/24 revealed a focus area for attend activities of choice with interventions that included provide in room activities as needed and required. During an observation on 5/13/25 at 8:56 am, Resident #4 was observed in bed, nonverbal, and staring at the door. During an observation on 5/13/25 at 9:16 am, Resident #4 remained in bed, nonverbal, and was staring at the ceiling. During an observation on 5/13/25 at 10:41 am, Resident #4 was still in bed in the same position, continuing to stare at the ceiling. During an interview on 5/13/25 at 10:43 am, CNA A stated that Resident #4 was nonverbal. CNA A stated Resident #4 typically did not leave his room. She stated that she was not aware of any in-room activities provided to him and had only observed him in bed. She stated that Resident #4 had not been provided with any items for engagement and stated that activity provision was the responsibility of the activities staff. During an interview on 5/14/25 at 12:42 pm, the Activities Director stated that Resident #4 did not have in-room activities provided and was unable to clarify the reason. She stated that Resident #4 did not have a radio or similar form of entertainment while in bed. She expressed uncertainty regarding the potential risks of limited stimulation and stated that she was not familiar with Resident #4's cognitive level. The Activities Director stated he enjoys listening to music and had not thought about getting him a stereo for his room to enjoy. During an interview on 5/14/25 at 12:46 pm, the Administrator stated that Resident #4 participated in facility activities and was frequently out of bed. She stated that he attended events such as holiday parties for Mother's Day and St. Patrick's Day. She stated that the Activities Director provided in-room engagement such as hand painting and other creative tasks at bedside. Record review of the facility's Life Enrichment Activity Guidelines dated 04/2020 revealed The community will provide, based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support residents in their choice of activities, both facility-sponsored group and individual activities and independent activities .

Based on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the facility's only kitchen. The facility failed to ensure: Food that was beginning to rot (discoloration and had rotten smell) was discarded. Staff knew how to check the sanitizer level in the dishwasher. Staff knew how to wash their hands. Food was dated per the facility's policy. Food was not stored on the floor. The dry storage and refrigerator were clear of debris and food under the shelves. These failures could affect residents who received meals prepared from the kitchen at risk for food borne illness and cross contamination. Findings included: Initial observation on [DATE] beginning at 9:05 a.m. of the facility's only kitchen revealed: The refrigerator revealed: the bananas in the refrigerator were simultaneously green and brown and the sandwich snacks were not dated. The dry storage revealed: food debris including an apple were under the shelves; 13 boxes of canned goods were on the floor; a box of rotting potatoes on the shelf that were slimy. At that time, The DM said the night shift was responsible for putting up the cans and sweeping under the shelves. She said she had spoken to the night shift about this before. The DM stated she did not know how old the potatoes were because the box was not dated. In an interview on [DATE] at 9:20 a.m. DA J and DA K stated potatoes going bad had had been like that since they were hired. They said they cut off the bad parts and did the best they could. Observation and interview of the walk-in freezer revealed food debris, including 2 whole hashbrown cakes, under the shelves. At the time of the observation, the DM stated it was not ok, and it had been a while since she had been out to check the walk-in freezer and she had to rearrange the shelves. At the end of the initial kitchen on [DATE] observation DA K washed her hands and then turned off the faucet with her bare hands. Observation and interview on [DATE] at 1:26 p.m. DA J said he worked at the facility since February and had no training on how to test the sanitizer level on the dish machine, but he was happy to try. DA J ran the dish washer and tested the sanitizer level with the test strips that should be used on the three-compartment sink. At that point the DM took over. The DM said DA J was using the wrong test strips. The DM got the right test strips, and the dish machine was within the right parameters. In an interview on [DATE] at 4:24 p.m. the DM stated the facility's policy on dating was everything was to be dated when it was received. The DM said it was policy things were dated when they were cooked, labeled what they were and when they expired. The DM said she did some investigation and said the rotten potatoes were 3.5 weeks old. The DM said she did not know how the bananas were both green and brown at the same time, but it came off the truck that way, but the dietary staff would peel them for the residents and if they were bad the banana would be thrown away. The DM said the afternoon shift was responsible for putting up food when it came in off the truck every night. The DM said the expectation for washing hands was to wet hands, soap, wash up to wrist, rinse, dry with paper towel, use a new paper towel and turn off the faucet with a new paper towel. The DM said she felt the DAs were good about doing that when she was in the kitchen. The DM said she said she did handwashing proficiencies at the end of August. The DM said she thought DA J was trained on the dishwasher when he was at another facility. The DM said DA J was using the test strips that were up on the testing area. Review of the facility's policy and procedure on Preparation of Foods, effective date [DATE], revealed: Food is to be prepared by methods that conserve nutritive value, flavor and appearance. Review of the facility's policy and procedure on Food Storage, effective date ,d+[DATE], revealed: All food purchased will be wholesome, manufactured, processed, and prepared in compliance with all State, Federal, and local laws and regulations. Food will be handled in a safe and sanitary method to prevent contamination and food-borne illness. Process: Foods are stored at least 6 inches off the floor. Separate raw animal foods, such as eggs, fish, meat, and poultry from ready to eat foods such as produce. Cooked and ready to eat foods are stored above raw foods (including shell eggs) in the refrigerator to prevent cross-contamination. Review of the facility's Cleaning Schedule (undated) revealed: Daily/After Each Use Cleaning Schedule Log: Floor, Freezers. Review of In-service dated [DATE] revealed the DM in serviced the dietary staff on handwashing.

Based on observation, interview, and record review the facility failed to treat residents with respect, dignity and care for each resident in a manner that promotes maintenance or enhancement of his or her quality of life for 13 of 13 residents in the confidential group interview. Staff used cell phones in residents' presence causing residents to feel disrespected and ignored. Staff had residents sit at assigned seating in the dining room. Staff labeled resident's clothing in large print over their clothing. These failures could result in a diminished quality of life for the identified residents and could affect additional residents by causing a loss of self-esteem and increased isolation. The findings included: Observations on 10/1/24 at 10:06 a.m. during initial rounds revealed Resident #9 (unsampled) was in a wheelchair in his room. His t-shirt was labeled in black marker about 2 inches wide. In an interview on 10/1/24 at 10:47 a.m. Laundry Aide I said sometimes family members labeled the shirts and sometimes the housekeepers had to do it. Laundry Aid I said they would go up and down the hall and find out who an unlabeled piece of laundry belonged to and label it. Laundry Aide I confirmed they would always label it 1 -2 inches big and on the front of the shirt. In an anonymous interview on 10/1/24 at 11:30 a.m. a resident said the CNAs just sat in the halls playing on their phone. The resident said it was an open secret and there was no use complaining about it. Observation on 10/1/24 at 11:50 a.m. revealed Resident #12 happily sitting at the center table in the dining room. CNA G moved Resident #12 from the center table to a corner table where he was facing the corner while telling him why don't we move you to another table? CNA G then moved a second resident. In a second anonymous interview on 10/1/24 at 2:10 p.m., the resident asked to speak with surveyor. The resident stated the nurses were nice, but the CNAs were on their phones all the time and they (the aides) could be using that time making sure the residents were ok and not wet. The resident said it felt like the aides were ignoring them. During the confidential resident council meeting on 10/2/24 at 10:00 a.m. 8 alert, lucid residents stated the staff were on their phone while residents were either waiting for care or receiving care. One resident stated they had to wait 40 minutes for care, and they already had a rash on their bottom. The residents were in 100% agreement the staff were on personal calls that could take hours. One resident said the evening shift was worse than the day shift. When asked how long it took for the call light to be answered, one resident responded, it's like getting to the center of a tootsie roll pop, no one knows. The residents when asked if there was one thing that could be changed said they would like the staff off the phones because the staff were like zombies when they were on them. The other residents said they would like to be treated like adults and not on house arrest. Interview on 10/2/24 at 1:27 p.m. LVN F stated some aides were on their phones more than others and they had seen the aides on the phone in the dining room. LVN F had seen aides on the phone in the resident rooms. Observation on 10/2/24 at 2:00 p.m. revealed residents on their smoke break, there was one staff present texting on their phone not paying attention to the residents. Interview on 10/2/24 at 4:55 p.m. LVN C stated he saw aide on the phone all the time. LVN C stated he told the aides to get off the phone, but they got right back on the phone and what was he supposed to do then? In an interview on 10/3/24 at 4:53 the DM stated there was assigned seating, but the residents had been sitting in those seats forever. In an interview on 10/3/24 at 4:58 p.m. with the DON and ADON, the DON said the last time she had assigned seating was grade school probably. The ADON said we do have assigned seating, it had to be changing because we have had some changes, the only residents who were really assigned were the residents at the feeder table because they needed to be there (residents needing assistance with eating). The DON said that was how the trays came out and the nurses did not want the residents waiting a long time for the residents at a table to wait for their food. The ADON said she made the seating chart. The DON said the staff cell phone use was a constant battle and she talked to the staff when she saw it. The DON said the staff did use their cell phones when they were clocking in and clocking out, but the staff should not be using the phone in the middle of providing care. The DON said she would feel bad if she was receiving care while someone was on the phone while providing care. The ADON stated they asked families to label clothing for the residents when they brought it in. The ADON said if the clothes were not labeled the staff would label it, but some did get missed. The DON held her fingers apart approximately 1.5 - 2 inches apart and said that was how big the labeling was. When held against her name tag, the name tag was approximately half the size as what the resident's label was. The DON said if helped keep her clothes from getting lost she would not mind. Review of the Nursing Facility Resident Rights posted in the facility revealed: Residents had the resident to be treated with dignity, courtesy, consideration, and respect.

Based on observation, interview and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 3 of 5 residents (Residents #17, #18 and #51) reviewed for transfers and supervision in that: Nursing staff and Resident #17's doctor were not aware Resident #17 had his right leg secured to his footrest with a gait belt. CNA A transferred Resident #18 from his bed to his wheelchair by taking him from his under arms. CNA G and CNA H transferred Resident #51 from his wheelchair to his bed taking him from under his arms and by the back of his pants. These failures could put residents at risk of accidents and serious injuries which could result in a reduced quality of life. Findings included: Resident #17 Review of Resident #17's Admission Record dated 10/2/24 revealed he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included stroke, hemiplegia of the right side, and convulsions. Review of Resident #17's Quarterly MDS assessment dated [DATE] revealed: He had a mental status score of 3 of 15 (indicating severe cognitive impairment) He was identified as having no range of motion impairment and he used a wheelchair. He received 232 minutes of occupational therapy. Review of Resident #17's Order Summary dated 10/2/24 revealed no order for any type of enabler. Review of Resident #17's care plan initiated 6/12/23 revealed: The resident has limited physical mobility related to weakness. Goal: the resident will demonstrate the appropriated use of wheelchair to increase mobility through the review date. Identified interventions included: PT/OT evaluation and treatment as per MD orders initiated 6/12/23. Resident has one-sided weakness initiated 6/12/23. Locomotion: Resident uses wheelchair for locomotion on and off unit. Requires limited to extensive staff assistance to propel. Initiated 6/12/24, revised 9/4/24. Alteration in mobility related to inability to ambulate, generalized weakness, inability to turn and reposition self, status post hemiplegia right dominant side. Goal: Resident will maintain current mobility status throughout the review date. Identified interventions included: -PT/OT to evaluate and treat as indicated -Assess resident's potential for Restorative Program as needed -Identify and address underlying cause of impaired mobility. -Provide appropriate level of assistance to promote safety of resident. -Instruct resident to use handrails in corridor. -Monitor resident's gait and assist as necessary. -Provide assistive devices as required -Modify environment as needed to enhance mobility -Encourage resident to participate in ambulation and praise. There was no care plan for the use of a device to the ankle. Observation on 10/1/24 at 1:41 p.m. revealed Resident #17 in the lobby with his right leg secured to the foot-rest pole with a gait belt. Resident #17 requested a nurse to look at his contracted arm. LVN H came and repositioned the arm and did not ask Resident #17 if he needed his right leg repositioned. Observation on 10/2/24 at 9:42 a.m. revealed Resident #17 was up in his wheelchair in the lobby with his right leg secured to the wheelchair with a gait belt. Observation on 10/2/24 at 12:13 p.m. revealed Resident #17 was up in his wheelchair in the dining room with his right leg secured to the wheelchair with a gait belt. Observation on 10/2/24 at 1:25 p.m. revealed Resident #17 up in his wheelchair in the lobby with his right leg secured to the wheelchair with a gait belt. In an interview and observation on 10/2/24 at 2:34 p.m. LVN C stated he did not know anything about Resident #17 having a gait belt around his ankle (securing right leg to wheelchair). LVN C went to Resident #17's room to check. Aides were preparing to transfer Resident #17 from his wheelchair into his bed. LVN C observed that Resident #17 did have the right leg secured to the wheelchair footrest with a gait belt. LVN C stated there was no way Resident #17 could take the belt off and took the belt away from the aides. In an interview on 10/2/24 at 2:39 p.m. PT D stated the therapy department had found Resident #17 out of bed with the gait belt around his leg (securing right leg to wheelchair footrest) when he was not in therapy. PT D stated Resident #17 should not have it on unless he was being transported from point A to point B because it could cause pressure. In an interview on 10/2/24 at 2:41 p.m. the DON stated Resident #17 had redness to the bilateral lower legs. The DON stated she did not know anything about a gait belt around Resident #17's right leg. LVN C explained to the DON his observation of Resident #17 with the gait belt around the wheelchair and he (LVN C) was sure it was therapy that applied the gait belt. The DON stated therapy should be taking the belt on and off (with transport). LVN C explained Resident #17's leg bowed out so his foot would fall off the foot pedal during transport. In an interview on 10/2/24 at 2:54 p.m. PT D stated Resident #17 was currently on OT and most days he was already out of bed when therapy came and got him. PT D stated Resident #17 had hemiparesis (Paralysis) on the right side of the body. PT D stated therapists put the gait belt on Resident #17's leg while transporting him to the gym but immediately took it off when they arrived at the gym. PT D stated they (therapy) secured Resident #17's leg to the foot pedal because Resident #17's foot would fall off and cause him pain. PT D said Resident #17 was not supposed to have the belt around his leg when he was not in therapy, and he (PT D) never issued an order saying the aides could use the belt to secure Resident #17's leg in transport. PT D stated maybe the aides did not know Resident #17 was not supposed to use it when not in therapy because Resident #17 would ask for it. PT D stated he had never assessed Resident #17 for the use of the belt. In an interview on 10/3/243 at 8:55 a.m. the DON stated they put a cradle on Resident #17's wheelchair yesterday (10/2/24) to hold his leg in place better than the belt and ordered him a bigger wheelchair. The DON stated what she found out was therapy started using the belt in transport and the CNAs kept going with it. The DON said the aides told her therapy told them to use it and everyone just went along with it. The DON said Resident #17 could not move his leg voluntarily. The DON repeated Resident #17's foot would not stay on the wheelchair footrest without the assistance of something securing the leg. The DON stated the facility initially tried a pillow and the pillow did not work. The DON said the facility could try a bigger wheelchair because that would make for a wider foot base and the facility talked about a foot board yesterday but the facility did not have one right now. The DON stated the gait belt was the first thing tried. The DON said there was no monitoring because the nurses did not know it was there either because therapy did not communicate it needed to be used or the aide just saw it and thought it was a good idea. In an interview on 10/3/24 at 9:33 a.m. Resident #17's doctor stated he did not give an order for Resident #17's leg to be secured to a wheelchair the Doctor would not give an order like that. The Doctor stated the facility did not tell him Resident #17's leg was being secured and he did not know how long that had been going on. The Doctor said when he saw Resident #17, he was usually and bed. In an interview on 10/3/24 at 9:46 a.m. Resident #17 stated he was much more comfortable with the leg cradle the facility provided. Resident #17 was unable to say how long the staff used the belt. In an interview on 10/3/24 at 10:19 a.m. Resident #17's Responsible Party stated Resident #17 had the belt to keep his leg on the wheelchair. The Responsible Party stated Resident #17 had it a little longer than a month. The Responsible Part was not sure if the nurses were aware if Resident #17 had it. In an interview on 10/3/24 at 10:38 a.m. PT D said he was aware of Resident #17's history of convulsions but Resident #17 never had one at the facility. PT D said Resident #17 had the belt for his leg for approximately 2 months, it started when Resident #17 was in physical therapy. PT D said they usually did therapy with Resident #17 after lunch when he was awake so if any observations were in the morning the aides put it on. PT D said Resident #17 did not have therapy on 10/2/24. PT D said he never told the aides to put the belt on Resident #17 and had provided no in-services on how to do it. In an interview on 10/3/24 at 11:04 a.m. CNA E stated Resident #17 had the belt for months (was unable to recall exact time). CNA E stated she received no training to put it on and therapy never instructed the aides to put it on. In an interview on 10/3/24 at 10:58 a.m. the Treatment Nurse confirmed Resident #17 had skin tears to his legs. The Treatment nurse stated that she was not able to determine how skin tears occurred. The Treatment Nurse stated she never saw Resident #17 with the belt on because she did the treatments when he was already in bed. In an interview on 10/3/24 at 11:08 LVN F stated she did not know anything about a gait belt to Resident #17's leg. LVN F said she repositioned Resident #17's arm on 10/1/24 and did not notice the belt on Resident #17's leg and monitored the dining room [ROOM NUMBER]/2/24 and did not notice the belt on his leg. LVN F stated she knew the aides got Resident #17 up on 10/2/24. RESIDENT #51 Review of Resident #51's Admission Record dated 10/2/24 revealed he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including brain cancer, esophageal cancer, muscle weakness, and repeated falls. Review of Resident #51's Admission MDS, dated [DATE], revealed: He had a mental status score of 14 of 15 (indicating he was cognitively intact) He used a wheelchair. He needed partial/moderate assistance for chair-to-bed transfers. He was on hospice care. Review of Resident #51's Care Plan revealed: Resident had and ADL self-care performance deficit related to disease process Terminal Prognosis. The identified goal was: The resident will maintain current level of function through the review date. Identified interventions included: Transfer: The resident required limited staff assistance with transferring. Initiated on 9/13/24. Observation on 10/1/24 revealed CNA G and CNA H placed Resident #51's wheelchair at a 90-degree angle to the bed and locked the wheelchair. Then both aides hooked their arms under Resident #51's arms and grabbed the waistband of his pants. Resident #51 dangled while the aide pivoted and placed Resident #51 in bed. In an interview on 10/2/24 at 2:05 p.m. CNA H stated she remembered CNA G was on the other side of Resident #51. CNA H said they hooked their arms under Resident #51 and put him to bed. CNA H stated that was how they were trained to do transfers. CNA H stated Resident #51 said Resident #51 was able to bear weight, but he was feeling weak on 10/1/24. CNA H said they held Resident #51 by the pants because when he was dead weight, he pulled everyone down. CNA H said she did not know why they did not use a gait belt with Resident #51 because it would be safer. CNA H said the aides had to get the belts from therapy and there was only one resident who had a gait belt on the hall 24/7. RESIDENT #18 Record review of Resident #18's admission record dated 10/01/24 indicated he was admitted to the facility on [DATE] with diagnoses of dementia, unsteadiness on feet, reduced mobility and muscle weakness. He was [AGE] years of age. Record review of Resident #18's MDS dated [DATE] indicated in part: BIMS score = 03 indicating resident had severe impairment. (Chair/bed-to-chair transfer: 02 Substantial/maximal assistance = Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort). (Sit to stand: The ability to come to a standing position from sitting in a chair, wheelchair, or on the side of the bed. 01. Dependent - Helper does all of the effort. Resident does none of the effort to complete the activity or the assistance of 2 or more helpers is required for the resident to complete the activity). Record review of Resident #18's care plan revised 09/25/2024 indicated in part: Focus: I have an ADL self-care performance deficit r/t impaired mobility & poor safety awareness. GOAL: The resident will maintain current level of function through the review date. Interventions: The resident is dependent on staff for assistance with transferring. During an observation on 10/01/24 at 03:34 PM CNA A transferred Resident #18 from his bed to his wheelchair by herself. CNA A took Resident #18 from underneath his armpits and moved him into his wheelchair. During the transfer Resident #18 was unable to bear any weight. During an interview on 10/02/24 at 02:46 PM CNA A said the way she knew the transfer status of any resident was by asking the resident, seeing if a resident had a mechanical lift sling under them or by asking the nurse. CNA A said they had gait belts and that they used them sometimes for transfers. CNA A said the way she transferred Resident #18 was not necessarily safe and that it was kind of difficult as he did not help with the transfer. CNA A said that at times it took 2 aides to transfer the resident but had not thought about getting help. CNA A said if she transferred Resident #18 by herself and not use a gait belt, she could injure the resident such as dropping him. During an interview on 10/03/24 at 04:20 PM the DON was made aware of the observation of how CNA A transferred Resident #18 from his bed to his wheelchair . The DON said the transfer status was in the CNAs care plan also known as the Kardex which was located in the CNAs computer system and all the CNAs had access to that. The DON provided a copy of the Kardex but it was not clear on the transfer status for Resident #18. The DON said the Kardex just indicated the resident is dependent on staff for assistance with transferring but was not specific as to how many staff to assist or how. The DON said CNA A should have used a gait belt for the transfer or gotten help. The DON said if the CNA transferred Resident #18 by herself and by his armpits there was a chance the resident and the staff member could be injured. The DON said the staff had competencies done on transfers as well and were done by the ADON. The DON said the failure probably occurred because CNA A had gotten nervous. During an interview on 10/03/24 at 04:24 PM the ADON said she performed competency checks to include transfers. The ADON said the competency was on the use of the mechanical lift but not necessarily on gait belts or staff conducting transfers by themselves. The ADON said they would have to conduct training on gait belt use. The ADON provided a copy of the competency for CNA A. During an interview on 10/03/24 at 05:28 PM the Administrator was made aware of the transfer of Resident #18 and Resident #51 performed by the CNAs. The Administrator said the CNAs should have known to use a gait belt and also to know where to check for the transfer status of each resident. The Administrator said if the CNAs did not perform the transfer safely it could result on the resident and staff getting injured. The Administrator said they would have to conduct more training. Record review of Resident #18's and Resident #51's Kardex dated 10/03/2024 indicated in part: Transferring: The resident is dependent on staff for assistance with transferring. (Note: The Kardex did not specify how to transfer the resident). Record review of the facility's policy titled Safe lifting and movement of residents dated 07/2017 indicated in part: In order to protect the safety and well-being of staff and residents, and to promote quality care, this facility uses appropriate techniques and devices to lift and move residents. Resident safety, dignity, comfort and medical condition will be incorporated into goals and decisions regarding the safe lifting and moving of residents. Manual lifting of residents shall be eliminated when feasible. Staff responsible for direct resident care will be trained in the use of manual (gait/transfer belts, lateral boards) and mechanical lifting devices.